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Telemedicine & e-Health

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Presentation on theme: "Telemedicine & e-Health"— Presentation transcript:

1 Telemedicine & e-Health
Nicolette de Keizer Dept Medical Informatics University of Amsterdam

2 Evolution of telemedicine
1924: radio doctor 1975 first RCT “Comparison of television and telephone for remote medical consultation” in NEJM NASA checks vital signs of astronauts ’90: introduction of the Internet

3 Outline Definitions: e-health, telemedicine Quality assurance
Laws and ethics Technical possibilities Impact on health care Factors for failure and success Example in Teledermatology

4 Definition Telemedicine
“ The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities” WHO(2002) Telemedicine is the use of telecommunication technologies to provide healthcare services across geographic, temporal, social, and cultural barriers J. Reid, 1996

5 Definitions: e-Health
51 unique definitions (Hans Oh, JMIR, 2005) administration of health data electronically (ESA) e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. (Eysenbach, JMIR, 2001) The use of internet technology by the public, health workers, and others to access health and lifestyle information, services and support (Wyatt, JECH, 2002)

6 Calling names Virtual Outreach Hospitals Without Walls
Reaching The Unreached Bridging the Urban-Rural divide

7 eHealth vs telemedicine

8 Quality assurance Code of behaviour
Certificate of (trusted) third party Code of behaviour Instructions for use Filters Certificate of (trusted) third party

9 Code of behaviour: e-Health code of Ethics
Sincerity: objectives, financial interest Honesty: no misleading information Quality: correct and recent information with acknowledgement Informed consent: use of data Privacy: carefull use of data Professional: professional care Responsible care provision

10 Laws and Ethics Autorisation – right to read and change information
Identification – is person X person X? Laws/Privacy Internet not restricted to country borders Responsibility - Who?

11 “I didn’t know it would go so fast”
Example NL Statement 20/3/05 Disciplines to internet physician Drug prescription via the internet should be prohibited Agree 44% Neutral 1% Disagree Minister surprised about internet development 55% “I didn’t know it would go so fast” March 2005

12 Example NL (2) College of Hospitals advices Patient and Internet, 20/3/2000 Buying health products via Internet occurs on a limited scale: 5% of interviewees once bought health products via the Internet (most commonly vitamines) Of the interviewees 71% do not intend to buy in the future. March 2000


14 Teleconsultation Videoconferencing (real-time) Store-and-forward

15 Entities involved in Telemedicine
Telemedicine Platform Desktop PC, Laptop,Palmtop/PDA Telemedicine Software Acquisition,Storage and display Transmission of patient related information Clinical Devices Digital ECG, Electronic Stethoscope, Digital Camera,Tele-pathology Microscope, X-Ray Digitizer Communication Media (mobile) phone, Internet, Bluetooth

16 Which settings benefits from telemedicine?
Only large distance Also small distance

17 Telemedicine – large distances
Developing countries Army Places hard to reach Disasters Space An evaluation of the first year's experience with a low-cost telemedicine link in Bangladesh. Vassallo DJ, Hoque F, Roberts MF, Patterson V, Swinfen P, Swinfen R. Journal of Telemedicine and Telecare, 2001

18 Mobile TMU

19 Telemedicine – small distances
Jail Shy, socially challenged people Pressure of work, shortage of personell Nursing homes

20 Impact on health care Quality of care Access to care Cost of care

21 Impact on health care Quality of care Diagnostics
Treatment (AIDS patients in South Afrika,Cell-life) Patient satisfaction (early treatment, no live physician) Cell-life

22 Outcome measures Quality of Care
Diagnostic accuracy Delay in treatment Preventable consultations Adherence to medication Quality of life Mortality and morbidity

23 Impact on Health Care Access to health care
Patients with communication disabilities (dumb, deaf) Isolated patients, hard to reach Independent of time / place Contact with fellow-sufferers Education

24 Outcome measures Access to Care
Patients satisfaction Timeliness disease detection Adherence to (treatment) advice

25 Impact on health care Costs of Health care
Prevention of diseases – lower costs for society Prevention of consultations Lower costs due to less specialist consultations Higher costs due to more consultations No valid evidence for cost reduction by telemedicine (Whitten, BMJ, 2002)

26 Typology of cost studies
Types: Cost analysis - What does the service cost ? Cost minimization - Does the service save money ? Cost effectiveness analyse - What is the balance between costs and effects? Perspective: patient, care provider, society?

27 Other outcome measures
Physicians satisfaction Technical aspects: quality of photo’s, performance of application Usability of the service

28 Factors of success and failure
Satisfaction patients and health care professionals Better involved patients Addition not replacement to physicians practice Failure Fear of technique Inaccurate Limitations in time, money and knowledge

29 Types Tele-Radiology Tele-Cardiology Tele-Pathology Tele-Ophthalmology
Tele-Dermatology Tele-Psychiatry Tele-Surgery Tele……..Anything

30 An example of a study in Teledermatology

31 Context High pressure on health care due to:
Shortage on full-time specialists Aging population Physical joint consultations 33% less referrals (Vierhout et al, Lancet, 1995) Modern information and communication technology  more possibilities  telemedicine

32 Teledermatology Telemedicine application in dermatology Dermatology:
High number of GP consultations (ca. 8%) Visual orientation Teledermatology worldwide and in NL: Local implementations and financial compensations No robust scientific evidence for effectiveness and efficiency (o.a. Eminovic et al, BJD 2007)

33 Conventional care versus teledermatologie
patient info Dermatologist GP Teledermatology GP Info + images advice Dermatologist 35% patiënt patient Less referals? Less costs?

34 PERFECTD Primary care Electronic Referrals: Focus on Efficient Consultation using Telemedicine in dermatology Virtual consultations between GPs and dermatologists

35 Website KSYOS TDCS®

36 PERFECT D: outcome measures
Unnecessary referrals Patient satisfaction Costs savings

37 PERFECTD methods Multicentre cluster RCT Randomisation GPs
Control group = conventional care / referral Intervention group = teledermatology All patients go to live dermatologist Cost minimizing study

38 Patient referred to dermatologist
Less consultations? Live dermatologist Patient referred to dermatologist Control group Intervention group Description signs + digital photos to derm Teleadvice + intervention GP Dermatologist decision: Consultation necessary or unnecessary

39 Less costs? Societal perspective Modelling cost components
GP Dermatologist Programme costs (camera, software, training, etc.) Patient Employer Cost value input: PERFECTD RCT, Handbook, experiment, expert opinion Monte Carlo simulatie (sensitivity & scenario analyse)

40 Cost Benefit Costs Benefits - less consultations to outpatient clinic
+ Time GP + investments (camera, website, internet) + training GP + easy to refer Benefits - less consultations to outpatient clinic - less try-outs by GP - Faster treatment in outpatient clinic

41 Cost model

42 Results 605 patients included 312 intervention, 293 control group
Preventable consultations: 39% intervention group, 18.3% control group Most important reason for difference is RECOVERY of patients Costs: Conventional care: Euro (95%CI, – 461.2) Teledermatology: Euro (95%CI, – 484.0)

43 Scenario analysis Unneccesary referals >17%
GP TD time <7.5 minutes

44 Scenario analysis Distance to GP < 55km Distance to dermatologist

45 Conclusions Less referals to outpatient clinic but no difference in costs Cost effective when teledermatology is used for specific patient groups or settings: Higher percentage unneccesary referals Larger distance to dermatologist Less time for GP ->integration TD with GP system

46 …Questions?…

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